COVID-19 diversity: A case of multisystem inflammatory syndrome in children masquerading as juvenile systemic lupus erythematosus

Abstract

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection may present with some systemic lupus erythematosus (SLE) manifestations intermingled with Kawasaki disease features. These emerging presentations were dubbed under the umbrella term ‘multisystem inflammatory syndrome in children (MIS-C)’. A one and half-year-old girl, admitted to Mansoura University Children’s Hospital (MUCH) with fever, bad general condition, vomiting, widespread maculopapular, vasculitic rash, hands and feet oedema, oral ulceration, arthralgia and lymphadenopathy. Moreover, bicytopenia, positive antinuclear, anti–double-stranded DNA antibodies and low C3 qualified her as a case of juvenile SLE. Despite the child received the initial therapy of immunosuppressive medication, her general condition deteriorated with fever persistence and rash exacerbation. At that time, the skin of her hands and feet started to peel. Thus, an expanded study for other alternatives was obligatory; SARS-CoV-2 infection testing revealed positive IgG serology, and retesting for lupus autoantibodies turned negative. HRCT chest showed bilateral basal consolidation with ground-glass appearance. Furthermore, Echo exhibited coronary artery dilation with thrombus inside. This evolution raised the concern for COVID-related MIS-C syndrome. This report provides a model of COVID-19 heterogeneity with protean immune-related manifestations. This case has a unique presentation that necessities its description, in order to provide a nidus for future studies in this new entity.

Skin manifestations in children with MIS‐C and COVID‐19: a narrative review

“…Both the CDC and WHO have set a maximum age beyond which a patient is not eligible for post COVID‐19 MIS‐C diagnosis. The maximum age limit varies between 18 and 21, but a general consensus exists that any patient younger than the age of 18 can be diagnosed with MIS‐C 25–27 …”

“…Diagnosis of COVID‐19 may be done either through RT‐PCR, serology, or antigen testing. Alternatively, exposure to COVID‐19 in the 4‐week period prior to presentation with MIS‐C‐like symptoms may also be considered regardless of definitive laboratory COVID‐19 diagnosis 25–27 …”

“…Alternatively, exposure to COVID-19 in the 4-week period prior to presentation with MIS-C-like symptoms may also be considered regardless of definitive laboratory COVID-19 diagnosis. [25][26][27] Management Every pediatrics patient diagnosed with MIS-C must be admitted to the hospital for monitoring and management. 28 Depending on severity, treatment could be limited to supportive care or may necessitate further interventions like fluid repletion and vasopressor care in case of vasogenic shock and inotropic care, mechanical ventilation, and PICU admission in case of cardiorespiratory complications.…”

“…These abnormalities are usually accompanied by organ system specific variations on blood sample testing, indicating multisystemic failure. Coagulopathies present with changes in PT, PTT and D-dimer, and myocardial dysfunction is most often detected with elevated Troponin or proBNP [25][26][27].…”

Reliability and reproducibility of antinuclear antibody testing in pediatric rheumatology practice

“…Clinical and laboratory features are similar, including ANA positivity ( 32 ). ANA positivity and illnesses mimicking pSLE are associated with other viral infections, including EBV, hepatitis C (HCV) ( 18 , 31 ), and recently SARS-CoV-2 ( 60 , 61 ). While environmental factors are thought to trigger SLE in genetically susceptible individuals, there is no clear evidence that viruses cause pSLE ( 32 ).…”